A Randomized Trial of Screening for Intimate Partner Violence in Young Women Leslie Davidson +, Niki Palmetto +, Kathleen Jones+, Vaughn Rickert+, Vicki Breitbart #, Jini Tanenhaus #, Tamu Aljuani #, Melissa Forbes #, Michelle Zeitler +, Lynn Stephens^ (+Mailman School of Public Health, Columbia University, #Planned Parenthood of NYC, ^Boston University) Supported by the Columbia Center for the Prevention of Youth violence. Funded as and ACE center by the CDC.

BACKGROUND IPV rates are highest among year olds  No evidence of effectiveness of screening, nor of potential risks to young women  Lack of validated screen instruments for adolescents

Our Prior Research 46% of young women reported physical or sexual violence in current relationship Did not mind being asked Health provider was best person to ask Most supported universal screening Requested screen begin with positive questions Equal proportion women reported participation Anonymous A-CASI survey of 645 ethnically diverse women (15-23yr) found:

Randomized Trial of Three IPV Screens 3 Screen Types:  “Basic”  “Healthy Relationship”  “Mutual”

Study Goals Primary: Physical violence by partner EVER in life and/or Sexual violence by anyone EVER in life Secondary: Current Physical violence and/or Sexual Violence (in past year) Women’s Experience with screens Provider’s Experience with screens

The “Basic” Screen (5 questions) In the Past Year: (Never, Seldom, Sometimes, Often, Always) My partner is suspicious that I am unfaithful My partner forced me to have sex when I didn’t want to. My partner hit, slapped, or physically hurt me on purpose Ever in your lifetime: (Yes / No) Have you ever been slapped, hit, or otherwise physically hurt by any partner? Has anyone ever raped you or forced you into a sexual act?

The “Healthy Relationship” Screen (7 Questions) “Basic” Screen PLUS: My partner respects me My partner treats me well Responses: Never, Seldom, Sometimes, Often, Always

The “Mutual” Screen (8 questions) “Basic” Screen PLUS: in the past year I am suspicious that my partner is unfaithful I forced my partner to have sex when s/he didn’t want to I hit, slapped, or physically hurt my partner on purpose Responses: Never, Seldom, Sometimes, Often, Always

Screen Results BasicHealthyMutual Total Any violence Ever (%) Ever Physical (%) Ever Sexual (%) * All non-significant * EVER IPV PREVALENCE By Screen Type

Screen Results BasicHealthyMutual Total Any Current violence (%) Current Physical (%) ** Current Sexual (%) Current IPV PREVALENCE By Screen Type ** p <0.04

How comfortable were you answering the questions? Did you answer questions honestly? Were you worried about computer confidentiality? How comfortable were you discussing violence with your provider? * All non-significant We asked the women:

Did the screen enable you to do a better job as a clinician? How helpful was screen in identifying IPV? Did the screen make the visit more efficient? How comfortable were you talking about violence? * All non-significant We asked the providers:

CONCLUSIONS No screening approach performed better than the others Given a higher baseline prevalence found previously in the same population, more work is needed to increase disclosure rates Intriguing finding that mutual screen elicited a higher prevalence of current physical violence - better understanding of participation in violence required before further trials

Acknowledgements Columbia University: Leslie Davidson, M.D. Vaughn Rickert, PsyD Kathleen Jones, MPH Michelle Zeitler, MPH Boston University: Lynn Stevens Planned Parenthood: Vicki Breithart Jini Tanenhaus Tamu Aljuani Melissa Forbes Supported by the Columbia Center for the Prevention of Youth Violence. Funded as an ACE center by the CDC

Screen Sensitivity and Specificity Sensitivity: 98% (150/153) Specificity: 90% (469/521) Computer screen Provider assessed Total Screen positive Screen negative Total

AGREEMENT Screen findings Provider assessed Kappa Any violence 208 (30%) 153 (23%).791 Any physical violence 139 (20%) 103 (15%).787 Any sexual violence 144 (21%) 95 (14%).727

Discussion and Assessment Screening results below Patient reports discussion with provider Pt reports no discussion provider reported violence No discussion/ Nonviolent assessment Negative for Violence 310 (63%)1163 (33%) Any violence 180 (87%)8 (4%)17 (8%) Physical violence (90%)4 (3%)9 (6%) Sexual violence (83%)7 (5%)14 (10%)

Comfort and Honesty (mean scores) More favorable Less favorable

Confidentiality (mean scores) More favorable Less favorable

Prevalence of violence Anonymous computer survey CADRI: 43% Confidential computer screening: 30% Provider assessed: 23%

FrequencyValid % Cumulative % AGE yrs yrs yrs Times Pregnant Never 1 time 2 times 3+ times Abortions None 1 time 2 times 3+ times Ever use of Birth Control Ever use of Condoms Ever use of OCP Ever use of Depo 9814 Ever had an STD Sexual active in last 6 months

Our Prior Research 46% of young women reported physical or sexual violence in current relationship 84% did not mind being asked 78% considered health provider the best person to ask them about violence Most thought universal screening should occur in a healthcare setting Anonymous A-CASI survey of 645 ethnically diverse women (15-23yr) found:

15-24 yr old women seeking care (n= 699) Consent and randomized Basic (222) Healthy Relationship (243) Mutual (224) Women Visit with Provider Evaluation of woman’s experience Assessment of violence Brief evaluation of screen (4 questions) Print out of screen responses Women Providers

POWER Sample size calculated based on an estimated current IPV prevalence of ~ 45%, and an expected risk difference of ~14% Our study found a screening prevalence of current IPV = ~ 12%, and ~ 5% difference between Basic and Mutual Therefore, we would have needed 460 women in each arm to achieve 80% Power